496804112-10-19-2023-21-AS-VBEI-CYN2SQ-20231218163930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804112
Report Date: 10/19/2023
Date Signed: 10/19/2023 06:07:45 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230809142110

FACILITY NAME:	LODGE AT PINER ROAD, THE		FACILITY NUMBER:	496804112
ADMINISTRATOR:	REYES, ALANA		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS: 46	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	06:05 PM

ALLEGATION(S):

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Staff are not responding to resident's emergency pendant.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, at approximately 2:00pm on 10/19/23, and met with Administrator Eric Perry.

LPA reviewed resident records, facility call bell records, staff records, food service records, and inspected the food supply. LPA conducted interviews with staff, and other related parties.

The investigation revealed that call bell report showed a pendant/call bell system event, R1's emergency alarm, that was set off showed elapsed time in response;This is a risk to the health and safety of a resident(s). This deficiency will be cited, 87303(i)(1)(2) - Maintenance and Operation. Facilities licensed for 16 or more... shall have a signal system which meets specified requirements, see LIC9099D.

Based on record reviews, and interviews during this investigation, the allegation of "staff are not responding to resident's emergency pendant." is substantiated. The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Appeal Rights Given to the Administrator
Exit interview conducted with the Administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230809142110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT PINER ROAD, THE	FACILITY NUMBER: 496804112
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/20/2023 Section Cited CCR 87303(i)(1)(2)	1 2 3 4 5 6 7	87303 Maintenance and Operation. Facilities licensed for 16 or more... shall have a signal system which meets specified requirements.This requirement was not met as evidenced by: Based on investigation, file reviews, interviews, facility failed to ensure staff are responding to emergency call bell alarm(s) in a timely manner.	1 2 3 4 5 6 7	Administrator to ensure all required facility staff are trained on the emergency pendant/call bell alarm system and are following facility's policy/procedures/staffing and ensuring a timely response in answering resident's emergency alarms to ensure that resident's
	8 9 10 11 12 13 14	LPA reviewed facilities emergency alarm pendant/call bell system event report, emergency alarm that was set off showed elapsed time in response which poses an immediate health & safety risk to resident(s) in care.	8 9 10 11 12 13 14	needs, health & safety are being addressed appropriately and within regulations. Submit proof of training by 10/31/23, include topics, trainer, date/time spent, attendees. Submit plan of correction, scheduled date for training(s) by POC due date of 10/20/23.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230809142110

FACILITY NAME:	LODGE AT PINER ROAD, THE		FACILITY NUMBER:	496804112
ADMINISTRATOR:	REYES, ALANA		FACILITY TYPE:	740
ADDRESS:	1980 PINER ROAD		TELEPHONE:	(707) 852-2234
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	92	CENSUS:	DATE:	10/19/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eric Perry-Administrator		TIME COMPLETED:	06:05 PM

ALLEGATION(S):

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Facility is not following resident's care plan.
Facility staff at not properly trained.
Facility is not providing food/meals that is of good quality and nutritious

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, at approximately 2:00pm on 10/19/23, and met with Administrator Eric Perry.

LPA reviewed resident records, staff records/training, food service records/menus, and inspected the food supply. LPA conducted interviews with staff, and other related parties.

The investigation revealed that shower schedules are set up for all residents, and staff are assigned to meet residents care needs, including showers if needed. Staff were assigned to R1 as needed for their showers and care needs, per revord reviews and interviews. All caregivers and med-techs, are trained for meeting the needs of residents in care; All staff have required direct care staff training per records review. Medication technicians have required training per-record reviews.

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20230809142110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT PINER ROAD, THE	FACILITY NUMBER: 496804112
	VISIT DATE: 10/19/2023

NARRATIVE

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LPA toured the kitchen and observed the food supply to be sufficient, with fresh vegetables, fruits, meats, and many other food items. LPA reviewed food service records, which shows food purchase records, and facility menus of meals.There was differing information obtained from what was reported to the Department. No information obtained to support that the violations occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, facility is not following resident's care plan, facility staff at not properly trained, facility is not providing food/meals that is of good quality and nutritious " are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator Eric Perry.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC9099 (FAS) - (06/04)

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